Talent: Project Nursing

Transcription

1 Talent: Project Nursing 2011 Dr. Ronald Cossman Dr. Jeralynn Cossman Philip Mason Katherine Harney

2 ABSTRACT Affinity for place is a key component to individual migra on decision-making. Recruitment to rural places is based, in part, on the assump on that individuals raised in a rural area have an affinity for rural places and are therefore more likely to return to their hometown or a similar rural area. We tested that affinity hypothesis in a pilot survey (N=1008) of nursing students in Mississippi. We asked Assuming that a suitable job opportunity (for example, salary, specialty area, etc.) was available, where would you want to work in Mississippi when you graduate? Fully 90% said they would be willing to work in Mississippi upon gradua on, assuming an appropriate job was available. We then matched responses with birthplace and high school (i.e., direct city-to-city matches). We also coded the respondents ci es via the rural-urban con nuum county code and calculated correla ons to similarly-sized communi es. Using a weighted average, of all respondents, more than half (59%) across all categories of birthplace chose a prac ce loca on in a county of similar size to the county in which they were. This is consistent with similar research by Costa, Schrop, McCord and Gillanders (1996), in which approximately half of family prac ce physicians wanted to establish their prac ce in a community similar to the one in which they were raised. While a majority (54%) stated a preference for large (250,000 or more residents) coun es, only 2% of all respondents chose rural coun es (<2,500 residents) and only 30% chose to relocate to small (2,500 19,999 residents) coun es. To obtain more nuanced results the responses were divided by the four county size categories for birthplace, all respondents. When we matched birthplace to reloca on preference, while 76% of large county na ves wanted to return to large coun es, only 15% of rural county na ves sought to relocate to rural places. Essen ally the same pa ern was found when we matched by county of high school gradua on. We speculate that students are self-selec ng out of rural op ons since a majority chose a hospital as a desired working environment and of those who cited a working specialty chose ER, labor & delivery, pediatrics, cri cal care, surgery, OB-GYN, neonatal and ICU special es typically found in larger ins tu ons. The survey results quan fy the role that affinity for community and desired work specializa on (as opposed to economic opportunity) plays in the migra on decision and reveals whether those raised in small towns yearn to return to a small town. This research could have fundamental implica ons for recruitment and economic development strategies, especially in rural areas. 1

3 INTRODUCTION Mississippi is a poor, primarily rural, state and as such faces shortages of health care professionals. Of the state s 82 coun es, 78 are Health Professional Shortage Areas (HPSA) in which there is a shortage of primary care medical providers. 1 The es mated underserved popula on (living in HPSAs) in the state of Mississippi is 32%, almost three mes the U.S. rate of 12%. 2 Por ons of all 82 coun es are listed as Medically Underserved Areas (MUA) in which residents have a shortage of personal health services. Recruitment of nurses is a challenge in any environment. In Mississippi there is an addi onal challenge in recrui ng to rural areas, as well as recrui ng to poor communi es (e.g., the Mississippi Delta). In 2009 the hospital registered nurse (RN) vacancy rate for the state of Mississippi stood at 5.0%, with subcounty health district RN vacancy rates ranging from 1-11%. 3 Based on previous research, we proposed that rural na ves (defined as those born and/or gradua ng high school in rural coun es) would have a greater affinity for rural areas and thus would be more likely to choose to relocate to similarly sized coun es upon gradua on from nursing school. The purpose of this study was to quan fy that affinity for rural places and develop a predic ve model of who would choose rural places so that rural and underserved health care areas in Mississippi could more efficiently and effec vely recruit nurses. An extension of our research ques on was designed to quan fy student support for a direct job matching program between nursing graduates and employers either in their geographic loca on of preference and/or nursing specialty preferences. LITERATURE REVIEW Much of the nursing recruitment literature is from the perspec ve of the hospital, 4 5 or specifically focuses on the hospital s recruitment interac ons with prospec ve nurses Less research has been done specifically on the recruitment of nurses and especially the recruitment of nurses to rural and underserved places. One study surveyed third year family prac oners and found that approximately half of the respondents desired to return and establish their prac ce in a small town (less than 10,000 residents), small city (10,000 50,000 residents) and moderate city (50, ,000 residents). 9 Interes ngly, the factor that ranked the highest was significant other s wishes, while ini al income guarantee ranked 8 th behind such factors as recrea on/culture and schools for children. Another study surveyed a wide range of health care training graduates (ranging from nurse prac oner and nurse midwife to physician) and found that a rural background, par cipa on in a rural-based training program, desire to serve community health needs, return to hometown and financial incen ves (e.g., educa on loan repayment) were significantly associated with a desire to establish a rural-based prac ce. 10 However comparisons of this research to Mississippi are limited because the researchers defined rural as less than 50,000 residents and not part of an urban area and only 13 of Mississippi s 82 coun es (16%) meet that criterion. Another factor that adds to the complexity of recruitment and reten on of nurses is that it is an expensive proposi on. One study es mated the total cost to replace an RN (in a hospital se ng) between $62,100 and $67,100 (2002 calcula on). 11 It is reasonable to assume that recruitment to a rural or underserved loca on is even higher, given the difficulty of iden fying and then marke ng to an individual who is willing to relocate to a rural and underserved area. There is some evidence of this rural recruitment penalty. By virtue of their loca on in rural areas it takes 60% longer to fill nursing vacancies compared to urban counterpart facili es. 12 2

4 SURVEY METHODOLOGY The Social Science Research Center obtained MSU human subjects protec on approval and conducted a pilot on-line survey of Mississippi nursing students during the spring semester of The pilot consisted of 101 respondents. The survey was modified based on comments from respondents and administered during the fall semester of The fall nursing student survey was conducted by the Wolfgang Frese Survey Research Laboratory at the Social Science Research Center at Mississippi State University. A web based survey was posted to the Internet at the beginning of the 2010 fall semester. An open-access URL (web address) was provided to deans of nursing programs throughout the state. All 22 public and private nursing programs in Mississippi were contacted and 16 par cipated in the survey. The total par cipa ng popula on was 4,527 (fall 2010 nursing student enrollment), total responses to the survey were 1,008 and the response rate among the par cipa ng nursing student popula on was 22%. Response rates at par cipa ng schools ranged from 2% to 100%. The response rates were due at least in part to a response incen ve program aimed at the individual nursing programs the total number of respondents for the fall 2010 wave was 1,008. The coopera on rate (completed surveys versus incomplete surveys, par ally completed surveys and refusals) was 86%. As such, this survey is based on a convenience sample. Individuals in various nursing school programs were not randomly sampled for par cipa on. Thus margin of error sta s cs are not applicable. All ques ons in the survey, unless otherwise noted, provided for only one response/choice, usually in the context of most important factor. Most ques ons also included an op on for Not sure and No comment. Finally, some ques ons include an op on for Other in which case the respondent was asked to explain in a pop-up text box. In all cases we examined the other responses, coded them, and, if appropriate, added them to the exis ng response categories. SURVEY RESPONSES We asked What was the single most important reason/factor for choosing their nursing program or school? More than a third (38.5%) said that the school was close to home. Nearly another third (29.8%) based their decision on the type of program (e.g., major, specialty area) offered. Once these two choices were selected, the percentage for other reasons fell off quickly. The next most important reason was friends a ended or recommended this school, at 5.8%. However, adding together all those categories that speak to the school s reputa on and offerings (type of program, friends a ended, parents a ended, and reputa on), this category accounts for 44% of the responses. A er examining the other response comments and recoding, the other category was reduced from 75 responses (7.3%) to 5 responses (0.5%). Most were added to exis ng categories, although two new categories were created, reputa on (4.2%) and accepted into the program (0.9%). (See also Appendix Table A1: Why Did You Choose This School?) 3

5 Chart 1: Why Did You Choose This School? Close to home Type of program (e.g., major, specialty area) offered Friends attended/recommended this school Scholarship/financial aid package Flexibility of class schedule Cost of tuition Parents/relative attended/recommended this school Reputation Close to current employment l Accepted into the program Not sure Other No comment 0% 5% 10% 15% 20% 25% 30% 35% 40% The majority of respondents in the survey (60.5%) were currently enrolled in associate degree in nursing programs. Another third (29.6%) were enrolled in bachelor of sciences degree in nursing programs. The remainder of students were enrolled in masters, doctoral, other or had no comment. (See also Appendix Table A2: Type of Nursing Program) Chart 2: Type of Nursing Program 1.8% 1.2% 6.9% 29.6% 60.5% ADN BSN MSN PhD/DNP Other 4

6 More than a third of respondents planned on gradua ng this academic year ( ), with 9.1% gradua ng in the fall of 2010 and 30.2% planning on gradua ng in the spring Almost half, 44.5% expected to graduate in the academic year. Table 1: Expected Graduation Dates Graduation Dates Percent N Fall % 92 Spring % 304 Fall % 153 Spring % 295 Other, Already graduated, No comment 16.2% 164 Total 100% 1,008 We asked Assuming that a suitable job opportunity (for example, salary, specialty area, etc.) was available, would you want to work in Mississippi when you graduate? Overwhelmingly (90.2%) nursing graduates responded Yes, I would work in Mississippi a er gradua on. Obviously the desire or at least the openness to remaining in state to work is high among nursing students. A cri cal factor to recruitment is making nursing students aware of job opportuni es within the state of Mississippi. (See also Appendix Table A3: Desire to Work in Mississippi) Chart 3: Desire to Work in Mississippi 3.1% 6.7% Yes No No Comment 90.2% We provided a list of possible reasons for not wan ng to work in Mississippi to the 68 respondents who indicated such. A fi h (20.6%) of the nursing students who would not work in Mississippi a er gradua on cited the loca on as their single more important reason, followed by lack of area ameni es (19.1%) and salary package (19.1%), two of which cannot be resolved. On the brighter side, 11.8% of students who do not want to work in Mississippi when they finish school desire to be close to their family outside of Mississippi, which is not a nega ve comment on the state. In addi on, no respondents felt Mississippi lacked addi onal training opportuni es or had a nega ve perspec ve on the working 5

7 environment and only 1.5% reported there were few job opportuni es for their spouse/partner. (See Also Appendix Table A4: Reasons for NOT Wan ng to Work in Mississippi) Chart 4: Reasons for NOT Wanting to Work in Mississippi Location Lack of area amenities Total salary package Close to family No comment Lack of future professional opportunities The public school system I do not believe that I can work in my specialty Climate (i.e., weather) Few job opportunities for my spouse/partner Lack of additional training opportunities Working environment/conditions WHAT DO NURSING STUDENTS WANT IN A JOB? 0% 5% 10% 15% 20% 25% We asked a series to ques ons to determine how important various job-related factors were in terms of making a reloca on decision. We asked about the rela ve importance ( very important, important, neutral, unimportant, very unimportant, not sure and no comment ) for 12 jobrelated factors: total salary package (e.g., loan repayment, signing bonus, reloca on expenses), working environment and condi ons (working hours, size or type of facility), where I can work in my specialty, job opportuni es for my spouse/partner, area ameni es (e.g., sports, parks, cultural ac vi es, restaurants), the public school system (K-12), availability of addi onal professional training opportuni es, climate (i.e., weather), size of the city, close to family, future professional opportuni es and wherever I can find a job a er gradua on. The 12 factors were presented in one table so that the respondent could see all the factors at once and respondents could choose the same response (i.e., very important ) for mul ple factors. We analyze the results of this series of ques ons in three ways. First, in rank order, what were deemed very important factors? Second, in rank order, what were deemed very important or important factors? Finally, when compared to the rank order of the list as presented to the respondents (which was inten onally rank ordered by what the literature suggested would be the most important factors), did any factors move up or down in rank? We repeat the analysis for unimportant and the remaining categories. The top job-related factor, cited by almost three quarters of nursing students (73.7%) was working environment and condi ons (e.g., working hours, size or type of facility), cited by 15.2% more students as very important than the next highest ranked factor, salary package (58.5%). Only three factors were cited as very important, by more than half of the respondents: work environment, salary package 6

8 and future professional opportuni es. In the next er were work in specialty (47.2%), wherever I can find a job (40.0%), the public school system (38.6%), professional training opportuni es (34.7%), job opportuni es for spouse (31.3%) and close to family (29.2%). Rounding out the bo om factors cited as a very important factor by less than a quarter of the respondents were area ameni es (14.8%), climate (14.7%) and size of city (13.6%). Table 2: Factors Important in Determining Where Participants Want to Live and Work After Graduation Very Important Important Factor Percent N Working environment 73.7% 24.6% Salary package 58.5% 36.0% Future professional opportunities 52.6% 40.1% Work in specialty 47.2% 37.9% Wherever I can find a job 40.0% 31.9% The public school system 38.6% 22.5% Professional training opportunities 34.7% 45.8% Job opportunities for spouse 31.3% 26.1% Close to family 29.2% 37.1% Area amenities 14.8% 36.7% Climate 14.7% 27.6% Size of city 13.6% 30.1% In addi on to very important, respondents could also choose important to reveal their preferences, although among the top six factors the category of very important outweighed the category of important. When the category of very important is combined with the category of important, respondents listed the job-related factor of working environment is cited by almost all respondents (98.3%) as being a major concern in their job preferences. See Chart 4a: Job Related Factors. In other words, virtually every respondent ranked the working environment in their future job to be the most important factor. Not surprisingly, salary package was second, cited by 95% of respondents as having some degree of importance. This was closely followed by future professional opportuni es, cited by 93% as having some degree of importance. The job factor work in my specialty was cited by 85% of respondents as having some degree of importance, followed by wherever I can find a job (72%) and the public school system (61%). Clearly, the top er, in which more than three quarters of nursing students cited as having some degree of importance, speak to the quality of the job experience (working environment, future professional opportuni es and work in specialty), although salary package was also in the top er. 7

9 Chart 4a: Job Related Factors Working environment Salary package Future professional opportunities Work in specialty Wherever I can find a job The public school system 0% 20% 40% 60% 80% 100% Very Important Important Of the next six job-related factors, professional training opportuni es were of par cular interest. See chart 4b: Job Related Factors. Although it ranked 7 th in term of being very important (35%), when the very important and important categories were combined, professional training opportuni es ranked above two of the upper er factors (81%), the job-related factors of wherever I can find a job (72%) and the public school system (61%). This further strengthens the argument that work environment factors are of paramount importance to future nursing professionals. Respondents felt propor onally less strongly about the remaining five job-related factors. Being close to family was very important to less than a third of respondents (29%) but overall was cited by two thirds (66%) as being of some importance. Job opportuni es for spouse was very important for almost a third (31%) and had some importance for more than half of the respondents (57%). Area ameni es was cited by less than a fi h (15%) as being very important but, nonetheless, had some importance for slightly more than half (52%). The size of the city was deemed as not important, with less than half (44%) claiming some importance, while climate (i.e., weather) was the lowest ranked factor, only 42% thought it had some importance. 8

10 Chart 4b: Job Related Factors Professional training opportunities Close to family Job opportunities for spouse Area amenities Size of city Climate 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Next, we look at how job-related factors were ranked by respondents as very important versus an expected ranking based on a review of the literature. Working environment and condi ons was the top concern, above salary package in second place; future professional opportuni es were ranked third, a much higher ranking than expected. These ranking con nue to suggest that the total work environment, opportuni es for advancement and ability to contribute are, as a package, a higher concern than simply salary. These results suggest that nursing students are looking beyond their first post-gradua on employment and are taking into considera on longer-term factors. That said, the job-related factor wherever I can find a job ranked fi h in terms of importance, reintroducing a pragma c view to the wish list. Although two-thirds of respondents were married or in a rela onship, respondents ranked the jobrelated factor job opportuni es for spouse/partner at 8 th, whereas the expected ranking due to marital status was 4 th. The job-related factor area ameni es ranked poorly at 10 th, followed by climate (11 th ) and size of city (12 th ). The factors deemed most important to soon-to-be nursing graduates are within the employer s control, (i.e., work environment and condi ons, salary, future professional opportuni es and ability for the graduate to work in their specialty). Factors beyond the control of the employer (e.g., job opportuni es for spouse/partner, proximity to family, area ameni es, climate and size of city) are not deemed terribly important by respondents. To report that a factor is not ranked as important is not the same as saying that that factor was unimportant. Almost a fi h of respondents consider Mississippi s climate to be unimportant or very unimportant in terms of a job-related factor. Similarly, the public school system, job opportuni es for spouses, size of city and area ameni es are judged to be unimportant or very unimportant. The remaining variables are considered very or slightly unimportant. In stark contrast, only 0.1% considered work environment to be unimportant or very unimportant. 9

11 The indifferent choice, neutral, appears to be the more popular with respondents wishing to leave their op ons open. Fully a third of respondents were neutral about size of the city (38.0%), climate (37.6%) and area ameni es (34.0%). In contrast only 1.5% of respondents were neutral about their work environment. Finally, less than 1% of respondents were unsure of how they felt about any of these job-related factors. However, almost 5% responded with no comment about a job opportunity for their spouse/partner, a much larger percentage that for any other factor. We can only speculate that they have not yet had a conversa on about post-graduate plans with their spouse/partner. Table 3: How Job Related Factors Were Ranked Factor Very Important Neutral Very Unimportant Not Sure No Comment Working environment 98.3% 1.5% 0.1% 0.0% 0.1% Salary package 94.5% 5.2% 0.2% 0.0% 0.1% Future professional opportunities 92.7% 6.3% 0.4% 0.3% 0.3% Work in specialty 85.1% 13.1% 0.8% 0.3% 0.7% Wherever I can find a job 71.9% 20.0% 5.1% 0.5% 2.5% The public school system 61.1% 19.4% 17.5% 0.4% 1.6% Professional training opportunities 80.5% 15.7% 3.0% 0.3% 0.5% Job opportunities for spouse 57.4% 20.6% 16.6% 0.5% 4.9% Close to family 66.3% 27.1% 6.2% 0.2% 0.2% Area amenities 51.5% 34.0% 13.7% 0.0% 0.8% Climate 42.3% 37.6% 19.7% 0.0% 0.4% Size of city 43.7% 38.0% 17.8% 0.1% 0.4% To qualify the respondent s freedom to choose a future job-related loca on, we asked if they had already made a job commitment upon gradua on (e.g., received a wri en or verbal agreement to work for a specific employer or medical facility). Eighty five percent said they did not have a commitment in hand, although 14% did acknowledge a commitment. For those respondents who had a commitment (N=143), a vast majority (90.9%) said the job was in Mississippi. (See also Appendix A5: Job Commitment) Chart 5: Do You Have a Job Commitment Upon Graduation? Do you have a job commitment upon graduation? a upon gradua on? 1% Yes No Other 85% 14% Is the job in Mississippi? Is the job commitment in Mississippi? 8% 1% 91% MS Yes MS No Other We then matched responses with birthplace, high school and loca on of nursing training (i.e., direct cityto-city matches). We also coded the respondents ci es via the rural-urban-con nuum county code and calculated matches to similarly sized county. 10

12 To quan fy the respondent s reloca on preferences we presented a table lis ng all municipali es in the state of Mississippi. Respondents could make up to five reloca on choices. Mississippi nursing students have one strongly held reloca on preference, but their preferences fall off quickly a er exhaus ng their third choice. By the fi h reloca on choice, only half (53.6%) expressed a preference. (See also Appendix A6: Reloca on Choices) Chart 6: Relocation Choices First choice Second choice Third choice Choice No Choice Fourth choice Fifth choice 0% 20% 40% 60% 80% 100% To test for affinity for hometown, we matched place of birth and high school gradua on with the respondent s first reloca on preference. In Table 4, we compare the respondent s place of birth county (anywhere in the U.S.) to the size of their first reloca on preference (74% of respondents were born in Mississippi). Using a weighted average, more than half (59%) of all Mississippi nursing student respondents across all categories of birthplace chose a prac ce loca on in a county of similar size to the county in which they were born (calcula ons not shown). This is consistent with similar research, in which approximately half of family prac ce physicians wanted to establish their prac ce in a community similar to the one in which they were raised. 13 To obtain more nuanced results, we then divided the coun es into four categories based on their 2009 popula on to measure whether na ves from rural and small coun es have a greater affinity for, and therefore are more likely to return to, rural and small coun es. (For a complete discussion of the matching methodology, see Appendix, Matching Methodology: Birthplace or High School to Postgraduate Preference) As illustrated in the table below, almost half (44%) of the state s popula on resides in large coun es and, as would be expected for low residen al density coun es, only 8% of the popula on resides in rural coun es. One fi h of the state s 82 coun es fall into three of the popula on categories, while two-fi hs are in the small category. When we examine the respondents, among those who reported a birth county (936 out of 1,008 or 93%), more than a third are na ve to large and moderate coun es, while only 5% are small county na ves (we speculate that those who did not report a birthplace either moved at an early age or were born outside the U.S.). More respondents reported their high school gradua on county (N=988). Here, the distribu on is approximately one third across large, moderate and small coun es, while rural coun es accounted for almost 10% of respondents. 11

13 Mississippi only All U.S. counties Table 4: Place of Birth Counties 2003 Population Birth County High School N Percent Percent Percent Large county:250,000 + residents % 35.9% 29.7% Moderate county: 20, ,000 residents % 38.3% 29.8% Small county: 2,500 19,999 residents % 21.2% 30.6% Rural county: Less than 2,500 residents % 4.6% 9.9% Totals % 100% 100.0% When the responses were divided by the four county size categories for birthplace, all respondents showed a majority preference (54%) for large (250,000 or more residents) coun es, while only 2% of all respondents chose rural areas and only 30% of small county na ves chose to relocate in small coun es. Reading the highlighted diagonal of the table, affinity for a similarly sized hometown varies drama cally, from 76% for large county na ves to 15% for rural county na ves. More than half of moderate, small and rural county na ves would move up the rural-urban con nuum to a larger county to prac ce nursing, leaving rural and small sized coun es behind. Respondents from large coun es comprised 34% of the survey popula on. A total of 75.8% who were born in a large county would choose a large county for professional prac ce, while 15.7% would choose a moderate sized (20,000 to 250,000 residents) county, and zero percent of those born in large coun es expressed an interest in reloca ng to a rural county. Among moderate sized county na ves, 43.6% would choose to remain in a moderate sized county, while 40.9% would choose a large size county, and 14% would choose a small county and only 1.2% would choose a rural county. Among small county na ves, almost half (47.6%) would prefer large coun es, a fi h (20.6%) would choose a moderate county, almost a third (29.6%) would choose a similarly sized (small) county, and only 2.1% would choose a rural county. Our last category, na ves of rural (2,500 residents or fewer) coun es, was by far the smallest category, totaling 40 survey respondents (5% of respondents). The largest segment (40%) would seek employment in large coun es, while a quarter (25%) would relocate to moderate sized coun es. A fi h (20%) would choose to move up the rural-urban con nuum code to a small county, while only 15% would seek employment in rural coun es. However, 43% of all those who chose a rural loca on were rural na ves (calcula ons not shown). Table 5: Responses by County Size Size of first preference county Size of birth Large county Moderate county Small county Rural county Total county N Percent N Percent N Percent N Percent N Percent Large county % % % 0.0% % Moderate county % % % 4 1.2% % Small county % % % 4 2.1% % Rural county % % % % % Total % % % % % *149 did not specify a relocation preference, did not know their birth county, had other commitment (i.e., military service) or did not comment. 12

14 If we seek to alleviate the nursing shortage in rural areas in Mississippi we face three linked issues. 1. Both the absolute (40 respondents) and rela ve (5%) size of rural na ves is insufficient to address health care worker shortages in rural areas in Mississippi. 2. Less than a fi h (15%) of rural na ves expressed an interest in remaining in a rural area. Thus, despite the recruitment and training, fully two fi hs (40%) would relocate to large coun es and a quarter (25%) would relocate to moderate sized coun es. 3. Respondent s choice of size of county may be a func on of their work preferences. Half of respondents (52%) expressed a specific desire to work in a hospital. See Chart 7: Desired Nursing Environment. In stark contrast, only 1.7% iden fied a Rural Health Clinic as their desired work environment. (See also Appendix A7: Desired Nursing Environment) Con nuing the hospital se ng theme, when respondents were asked about their desired area of nursing, services usually associated with a hospital were predominately men oned. See Chart 8: Desired Nursing Speciality. Cited the most frequently was emergency room (14.1%), followed by labor & delivery (10.6%), pediatrics (10%), cri cal care (7.2%), surgery (5.9%), OB-GYN (4.8%), neonatal (4.6%) and intensive care (4.3%). (See also Appendix A8: Desired Nursing Specialty) Chart 7: Desired Nursing Environment Hospital Traveling nurse Physician's office Not sure University health center Community public health Home health Nursing education Other Rural health clinic School nurse Nursing home Self employed Occupational nurse No comment Private duty 0% 10% 20% 30% 40% 50% 60% 13

15 Chart 8: Desired Nursing Specialty Emergency Not Sure Labor & Delivery Pediatrics Critical Care Surgery OBG/YN Other Neonatal Intensive Care Primary Care Clinic Teaching Cardiology Administration/Management Gerontology Operating Room Oncology Orthopedics Outpatient surgery Post-Partum Nursery No Comment 0% 2% 4% 6% 8% 10% 12% 14% 16% We conducted the same matching with the respondent s high school county and their first reloca on preference (86% a ended high school in Mississippi). See Table 6: Size of High School County. The primary finding is that 64% of respondents across all county categories (weighted average) would choose a similarly sized county to where they graduated high school (calcula ons not shown). However, when we divide the respondents by size of high school county, a different story emerges. While large-county high school graduate are drawn overwhelmingly to large coun es and almost half of moderate county high school graduates will choose a similarly sized place, less than a third of small county graduates would remain in a small county and 12% of rural county graduates would locate in a rural county a er gradua on from their nursing program. Again, the en re popula on of respondents showed a majority preference (54.6%) for large coun es, while only 1.7% of all respondents chose rural coun es. Respondents from large county high schools comprised 27% of the survey popula on. A total of 87.1% would choose a large county, while 8.8% would chose a medium county, 4% would chose a small county and none would choose a rural county. Among those who graduated from high school in moderate sized coun es, 41.4% would relocate to a large county, almost half (48.4%) would remain in a similarly sized county, 9.5% would relocate to small county and less than 1% would relocate to a rural county. Of those who graduated from high school in small sized coun es, 41.6% would choose to relocate to a large county, a quarter (26.3%) would move to a moderate, but larger county, almost a third (31.4%) would chose a similarly sized county and just 0.7% would move to a rural county. Our last category, those who graduated from high schools in rural coun es, has the most varia on in loca on preferences. Almost half (47.3%) would relocate to large coun es, a quarter (24.7%) would move to moderate sized coun es, 16.1% would prefer small coun es and 11.8% would choose to locate in a rural county. However, 73% of respondents who chose rural areas were rural county high school graduates (calcula ons not shown). 14

16 Size of high school county Table 6: Size of High School County Size of first preference county Large county Moderate county Small county Rural county Total N Percent N Percent N Percent N Percent N Percent Large county % % % 0.0% % Moderate county % % % 2.7% % Small county % % % 2.7% % Rural county % % % % % Total % % % % % Large: 250,000+ residents, Moderate: 20, ,000 residents, Small: 2,500-19,999 residents, Rural: <2,500 * 100 did not specify a reloca on preference, did not know their high school county, had other commitments (i.e., military service) or did not comment. We then considered dri, whether the respondents would choose different sized county as their third, fourth, or fi h choice. Keep in mind that respondents were simply presented with a list of ci es in Mississippi from which to choose. We found that there was no evidence of dri across the respondents reloca on choices before (results not shown) and a er controlling for the size of birth county (see Appendix Table A9). In general, those who chose large coun es as their first choice con nued to choose large coun es for their subsequent reloca on choices. However, the results suggest that there may be a slight propensity for respondents who a ended high school in large coun es to prefer a place of reloca on in a small county for their second, third, fourth, or fi h choices (see Appendix Table A10). Due to the small number of respondents when stra fied by preference reloca on and size of high school county, these results need to be interpreted with cau on. Nearly 90% of the respondents were female; so we also assessed poten al spousal employment opportuni es as they related to recruitment of nursing students. We asked first about their marital/ rela onship status and then about their ability to choose their post-gradua on reloca on loca on. Two thirds (66%) of Mississippi nursing students are either in a rela onship or currently married. The remaining third (32%) are single and not in a rela onship, separated, divorced or widowed. Table 7: Marital Status Percent N Single, never married and NOT in a relationship 22.1% 223 Single, never married and in a relationship 30.3% 305 Currently married 36.1% 364 Separated 1.4% 14 Divorced 7.5% 76 Widowed 0.6% 6 No Comment 2.0% 20 Total 100% 1,008 15

17 We then assessed the major factors in making a job-related reloca on decision. We inves gated the ques on, if the respondent was married or in a rela onship, was the respondent a leading or trailing spouse? Among respondents who were in a rela onship or married, a third (33%) would be the leading partner/spouse in choosing a job loca on. More than half (56.2%) would balance the decision with their spouse/partner. The reminder (5%), are unsure or had no comment. For purposes of recruitment, one third of married/partnered gradua ng nurses are in a posi on to make the choice about reloca on. Add the number of nurses who are single, never married and not in a rela onship, separated, divorced or widowed, and more than half (54%) of nursing respondents are in a posi on to decide independently or be in a posi on to lead in the decision making about post-gradua on job reloca on. On the other hand, more than half (56%) of those in the subset of in a rela onship or married would consult/nego ate with their spouse or partner and 6% would follow their partner/spouse. These finding could suggest that successful nurse recruitment could use a family unit approach in which the posi on and loca on/community are marketed to the couple, rather than the individual prospec ve employee to a ract this 42% segment of the nursing student community. Table 8: Major Factors in Making a Job-Related Relocation Decision Percent N In choosing a job location, which is more important? The location where YOU can find a job 33.0% 221 The location where your partner/spouse finds can find a job 6.3% 42 The job locations for you and your partner/spouse are equally important 56.2% 376 Not sure 3.1% 21 No comment 1.4% 9 Total 100% 669 We then measured interest in a poten al job-matching program beginning with this ques on. You have indicated your preferences about communi es you would be willing to work in when you graduate. Which of the following types of informa on would you be willing to share with poten al employers (e.g., Hospitals, Chamber of Commerce, Economic Planners, School Districts) in those communi es so they would know who is interested in working and living in their communi es? We are not currently collec ng this data but want to measure poten al interest in a future nursing job matching program. Some 80% were willing to provide their name and 81% were willing to provide their gradua on date. They were also amenable to providing their degree awarded (75%), their address (73%) and their mailing address (72%). Respondents were less willing to provide informa on that might preclude them from an opportunity or be perceived as nega ve informa on. Those included preferred reloca on area (58%), intended specialty (57%), grade point average (52%) and salary expecta ons (50%). 16

18 Chart 9: Interest in Potential Job Matching Programs Graduation date Name Degree awarded E mail address Mailing address Phone number Preferred relocation area Yes No Other Intended specialty Grade point average Salary expectations 0% 20% 40% 60% 80% 100% Finally, almost three quarters (73%) of Mississippi nursing school respondents were interested enough in a future nursing job matching program to provide an address for future follow-up. This is a solid measure of the willingness to par cipate in such a matching program. STUDY LIMITATIONS There was a lower than expected level of par cipa on by nursing programs and nursing students in this survey. As noted earlier, this survey is based on a sample of convenience. We did not have the op on of drawing a random sample from the nursing student popula on. Absent this control, the survey lacks sta s cal validity of a random sample. In addi on to cas ng doubts on the outcomes of this research, thus reducing the value of the research to nursing programs, the lack of validity limits the opportuni es to disseminate and publish in peer-reviewed journals. Without the valida on of peer-reviewed publica ons, it is very difficult to seek and obtain external funding to con nue and expand this research. To accomplish the sta s cal validity necessary to move forward we suggest two op ons. The first is to seek direct access to nursing students in the form of a random sample of student s university s from which to recruit respondents for an on-line survey. This would be preferably prefaced by a request from each nursing program dean/director to the student body to fully and quickly par cipate in the survey. The second survey op on would be to abandon the sampling scheme in favor of a survey of the en re nursing student popula on. In other words, all nursing students would receive the survey perhaps as part of the class registra on process, for example. Each nursing program would be strongly encouraged to par cipate in the survey in order to obtain a response from a representa ve sample of the en re popula on. More marke ng with the schools of nursing should be conducted to convey the value of this research in regard to the recruitment of students and the placement of graduates in loca ons of highest health care need. During the fall 2010 wave, we received responses from only 22% of par cipa ng program nursing students in the state (1,008 of 4,527), which was only 18% of all 5,546 nursing students in the state). 17

19 Moreover, response rates at par cipa ng schools ranged from 2% to 100% and six programs (with 1,019 students) had zero par cipa on. Full par cipa on is the more desirable of the two approaches since the sub-popula on of nursing students from rural areas is of the greatest interest but is also the smallest sub-set of the en re nursing popula on (5% to 10%). DISCUSSION In terms of measuring affinity for home or a return to rural places, the results do not inspire confidence or encouragement on ini al reading. Of all the nursing students who were either born or graduated high school in a rural county (popula on <2,500), only 15% and 12%, respec vely, would choose to return to a rural place upon gradua on. The majority would relocate to a large (250,000 people plus) city (40% and 47% respec vely) or a medium sized county (25% for both). In contrast, those who were either born or graduated high school in large coun es would overwhelmingly choose to relocate to a large county (76% and 87% respec vely). Even among those born or graduated in a small (2,500 to 20,000) county would chose to move to a large county (48% and 42% respec vely). These percentages must be put into perspec ve. Large county na ves and graduates comprised 34% and 27% (respec vely) of the survey respondents, while rural na ves and graduates comprised only 5% and 10% of the survey popula on. However, there are decidedly bright spots in the data. Size of city is the next to last category of importance for job environment and a majority of respondents want to work in a hospital se ng (likely because their special es of interest tend to be those found in hospitals), which may suggest that nursing students self-select to urban areas because of the nature of job that they seek. This conclusion is supported by the Mississippi of Nursing Workforce. All generic nursing students are prepared at the generalist level which includes specialty areas, i.e., labor and delivery, nursery, pediatrics, surgery, cri cal care, etc. Most nursing students desire posi ons they see as exci ng, glamorous, challenging, i.e., OR, ER, ICU, L&D, etc, and many rural hospitals have these special es available. Even the smallest hospitals have emergency departments. O en graduates select employment that offers a large volume of their par cular area of interest which leads them to larger facili es, wrote Wanda Jones, Execu ve Director of the Mississippi Office of Nursing Workforce. 14 The students responses lead us to believe that, if presented with a reasonable job offer that happened to be in a rural place, the job opportunity would trump loca on. This is supported by the fact that Wherever I can find a job ranked 5 th in the list of important job, where as loca on was at the bo om of the rankings. CONCLUSION AND RECOMMENDATIONS To contextualize the results presented here, we discuss them through the lens of recrui ng more nurses to rural areas in Mississippi. Thus, these are not blanket recommenda ons for health workforce policy change. They are objec ve-specific comments intended to spark discussion and considera on. Generally speaking, we found that the volume of nursing students from rural areas is insufficient to meet the health care workforce needs of Mississippi s underserved rural areas given that rural na ves account for less than 5% of total respondents. As such, we must wonder whether it is reasonable to set a goal of increasing the flow of rural na ves to nursing school and health care in general. Despite the findings about low rural na ve affinity for rural places, we argue that it is a reasonable goal to increase the flow of rural na ves to nursing school and ul mately to rural nursing prac ce. For recruitment of rural nurses, we speculate that a number of factors are in play. First, rural na ves bring with them a special understanding of the nature of rural health and community, a nuance that is 18

20 difficult to teach to urban na ves. Second, rural na ves are more likely to be coming from a community of poverty and few job opportuni es. Thus, they may be more likely to respond to financial incen ves such as financial scholarships or student loan repayment programs. To increase the flow of rural na ves to nursing and health care, some recommenda ons to consider include expanding exis ng or ini ate new programs (obviously pending appropriate funding, resources and commitment): star ng in elementary, junior high school and high school to nurture an interest in health care careers, especially in rural areas of Mississippi, expanding sciences summer camps, with an emphasis on biological sciences, in partnership with STEM (i.e., Science, Technology, Engineering and Mathema cs) recruitment camps, extending the exis ng rural scholars program (such as the one operated by the Northeast Mississippi Area Health Educa on Center (NE MS AHEC)) statewide from high school students to middle and elementary students, expanding the exis ng rural scholars program statewide to enroll more students, and increasing and targe ng school financial assistance for rural and underserved area students. Since the volume of rural nursing students is too small to fill rural vacancies, it may be possible to redirect the larger nursing student flows from large, medium and small coun es to rural areas, especially since job environment factors trump loca on. As the first piece of eviden ary support, consider ques on order. We asked the respondents (ques on #7) to indicate the level of importance of a dozen job environment factors. The number one factor was work environment, followed by three other work factors (salary, future professional opportuni es and ability to work in specialty). The ever-pragma c Wherever I can find a job? response ranked 5 th in importance. Two measures of the importance of loca on were ranked low. Area ameni es was ranked 10 out of 12 (15% considered it very important and 37% considered it important) and size of city ranked last on the list with 14% considering it very important and another 30% considering it important. We then asked (ques on #8) if, assuming a suitable job were available, would the respondent remain in Mississippi and work and 90% would. It was only a er asking those two ques ons that we asked respondents to list up to five reloca on preferences in Mississippi (ques ons #9). Based on the order of the survey ques ons and the importance that job working environment (ranked #1) had over size of city (ranked #12 th, last place), we have reason to conclude that an appropriate job would trump loca on, which bodes well for rural and underserved places. The next logical step would be to quan fy among large, medium and small county nursing students whether: there are fundamental reasons that they would reject a rural posi on, a job offer trumps loca on (e.g., would nursing students take the job opportunity in a rural area), This sort of data could be best collected through a series of focus groups with a range of nursing students in Mississippi. 19

21 To increase the a rac veness of rural posi ons, funding should be sought to support externships, residencies, and recruitment that would provide: prac cum and clinical rota ons for urban students in rural facili es and loca ons to increase exposure, awareness of prac ce la tude, freedom and addi onal responsibility in a rural work se ngs, and financial incen ves for nursing graduates to relocate to rural shortage areas. Rurality may also be a proxy measure for poverty. When, respondents were asked their reloca on preferences, they, clearly choose to move up the rural-urban con nuum to a larger county. However, they may be more interested in fleeing poverty than leaving low popula on density. Unfortunately, our survey popula on from rural areas is too small to test this hypothesis. Furthermore, we are not in a posi on to change the economic condi ons in a county. The ques on remains, however, would someone with wealth, in the form of a (rela vely) high paid health care job, be willing to relocate to a community in poverty? That is clearly a ques on for further inves ga on. Finally, a change in methodology should also be considered to collect longitudinal data on nursing students a tudes. Shi ing from a cross-sec onal survey (i.e., a random survey that is performed once or twice a year) to a longitudinal panel survey (i.e., a survey in which the respondents remain the same over me) would allow us to track changes in a tudes and priori es over me. Individuals priori es and goals can change drama cally between high school gradua on and gradua on from college due to the influence of training, changes in personal rela onships, and the process of maturing. A longitudinal panel survey could capture the effects of those changes over me. Future surveys could also measure the effect that any interven on or policy changes have on reloca on preferences, such as an expanded rural medical scholars program. FUNDING ACKNOWLEDGMENT This research was funded by the Dreyfus Health Founda on, as part of a grant awarded to it by the Kellogg Founda on. The findings, conclusions, and recommenda ons expressed in this publica on are those of the author(s) and do not necessarily reflect the views of the Dreyfus Health Founda on or the Kellogg Founda on. ABOUT THE AUTHORS Dr. Ronald Cossman is an Associate Research Professor and Research Fellow at the Social Science Research Center at Mississippi State University. Dr. Ron Cossman focuses his research on the spa al analysis and visualiza on of health condi ons. He uses Geographic Informa on Systems (GIS) and data visualiza on technologies to inves gate the rela onships between social and environmental factors and resul ng health outcomes such as death rate pa erns and chronic illness pa erns. His research has appeared in the Popula on Health Metrics, American Journal of Public Health, Popula on Research and Policy Review, the Interna onal Journal of Health Geographics, Health & Place and Journal of Maps. He has also authored several policy papers and policy briefs for the Mississippi Health Policy Research Center. He can be reached at: , or Ronald.Cossman@ssrc.msstate.edu 20